Information Collection

SAMHSA Data Security Requirements for Accessing Confidential Data

IC 261703 under ICR 202308-0930-001 · OMB 0930-0396.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0396 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Designated Agent F SAMHSA Data Security Requirements for Accessing Confidential Data	Form and Instruction
Form Designated Agent F Designated Agent Form SAMHSA Data Security Requirements for Accessing Confidential Data	Form and Instruction
Form Data Use Agreement Data Use Agreement Form SAMHSA Data Security Requirements for Accessing Confidential Data	Form and Instruction
Form SAMHSA RDC Student SAMHSA RDC Student Data User Acknowledgment Form SAMHSA Data Security Requirements for Accessing Confidential Data	Form and Instruction
Designated Agent F Designated Agent Form SAMHSA-Designated-Agent-Form.pdf	Form and Instruction
Designated Agent F Designated Agent Form SAMHSA-Designated-Agent-Form.pdf	Form and Instruction
Data Use Agreement Data Use Agreement Form Access-Agreement-20211101-Fillable.pdf	Form and Instruction
Data Use Agreement Data Use Agreement Form Access-Agreement-20211101-Fillable.pdf	Form and Instruction
SAMHSA RDC Student SAMHSA RDC Student Data User Acknowledgment Form Student-Advisor-Agreement_20221213_508.pdf	Form and Instruction
SAMHSA RDC Student SAMHSA RDC Student Data User Acknowledgment Form Student-Advisor-Agreement_20221213_508.pdf	Form and Instruction

IC Title:

SAMHSA Data Security Requirements for Accessing Confidential Data

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Designated Agent Form	Yes	Yes	Fillable Fileable
Form and Instruction	Data Use Agreement Form	Yes	Yes	Fillable Fileable
Form and Instruction	SAMHSA RDC Student Data User Acknowledgment Form	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Privacy Act of 1974 (Title 5 United States Code [U.S.C.] 552a)

FR Citation: 75 FR 28264

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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